Service Dogs Pick Up Scent of Diabetes Danger

About two times a night,
Shana Eppler
wakes up to an alarm and slips into her daughter Abbie's room to test the 8-year-old's blood sugar.

The growing field of diabetic-alert dogs that save their diabetic owners' lives by sniffing out when blood sugar levels get out of whack. Kate Linebaugh has details on Lunch Break.

Diagnosed with Type 1 diabetes at the age of 4, Abbie experiences low blood-sugar levels, a potentially dangerous condition known as hypoglycemia that can cause the loss of consciousness.

ENLARGE

Celeste, a yellow Labrador, has been at the side of 15-year-old Type 1 diabetes patient Dylan Calamoneri for about a year.
Andrea Calamoneri

The alarm Ms. Eppler uses to avoid a health emergency is a furry one named Gracie, an 70-pound, 3-year-old British Labrador retriever trained to sniff out high and low blood-sugar levels. When Abbie's sugar level rises or falls below a certain target at night, Gracie rings a bell and Ms. Eppler gets up.

Diabetic, or hypoglycemic, "alert dogs" are a growing class of service dogs best known for guiding the visually impaired, sniffing out drugs and bombs, or providing mobility assistance for people with severe disabilities. Most recently, they have been trained to sniff out cancer and oncoming seizures.
Toni Eames,
president of International Association of Assistance Dog Partners, estimates there are over 30,000 assistance dogs working in the U.S., including dogs that have been trained by individuals.

The dog's accuracy and speed can beat medical devices, such as glucose meters and continuous glucose monitors, according to doctors, owners and trainers. With their acute sense of smell, the dogs—mostly retrievers—are able to react to a scent that researchers haven't yet identified.

ENLARGE

Eight-year-old Abbie Eppler has avoided health emergencies thanks to Gracie, a 70-pound British Labrador retriever who wakes up Abbie's mother when the child's blood-sugar level rises or falls below a certain target at night.
KC Owens

For centuries, doctors diagnosed diabetes by identifying sweetness in the urine of a patient. That scent comes from glucose that isn't absorbed when a person lacks insulin, but the chemicals produced during low-blood-sugar incidents have yet to be identified.

"Whatever is being secreted in that drop in blood sugar…we just don't know what it is," says
Dana Hardin,
a pediatric endocrinologist who works for
Eli Lilly
& Co. in Indianapolis. Her goal is to identify what chemical compound the dogs smell, "not only to train dogs but to possibly make a device," she says.

Most of the interest in diabetic-alert dogs comes from people with Type 1 diabetes—and parents of children with Type 1—because they are more susceptible than people with Type 2 diabetes to serious problems of low blood sugar. Type 1 diabetes is an autoimmune disease characterized by the absence of insulin production, and requires daily insulin injections. People with Type 2, which is brought on by a combination of genetics, inactivity and obesity, have trouble processing insulin but don't necessarily require external insulin.

Incidence of Type 1 has been rising in the U.S. by about 2.5% to 4% a year for reasons scientists can't explain, according to several large-scale studies published in peer-reviewed medical journals. The number of people with Type 1 diabetes in the U.S. is between 1.3 million and 2.6 million, accounting for 5% to 10% of the total diabetic

Type 1 diabetics work to balance their daily intake of carbohydrates with external insulin. Prolonged high sugar levels can lead to complications such as heart disease, kidney failure and neuropathy. But trying to keep sugars at a low level raises the risk of hypoglycemia, which can be lethal, particularly if a patient loses consciousness while driving or alone.

Many people develop a condition known as hypoglycemia unawareness, meaning they no longer feel the hunger, listlessness and irritability that typically alerts diabetics that their blood-sugar level is falling.

"They don't get the signs. They just can be having a normal conversation, go from feeling fine to passing out," says Dr. Hardin.

Diabetics can use technologies such as continuous glucose monitors to help prevent these episodes, but these don't record blood-sugar drops until after they happen. So hypoglycemic-alert dogs can be lifesavers, says Dr. Hardin, who presented the first scientific research on the dogs at this year's annual American Diabetes Association conference in Philadelphia.

Using perspiration samples from patients whose sugars were below 65 milligrams a deciliter—normal is 80-120 mg/dL—she trained a two-year-old Labrador/Golden retriever mix to recognize low blood-sugar samples placed in blinded containers on a Lazy Susan-like wheel. Modeled after how police sniffing dogs are trained, trainers around the country use similar techniques. Dr. Hardin's dog was then paired with
Dustin Hillman,
a 36-year-old patient who suffered severe hypoglycemic unawareness.

Before he got the dog, Mr. Hillman lost consciousness due to hypoglycemia more than six times over the previous two weeks, requiring emergency services. In the three months after, the owner only lost consciousness once and never required emergency service, according to the study.

Since having Tippy—short for Tippecanoe—Mr. Hillman has finished his dissertation and will receive his Master's in Chemistry on Sunday from Purdue University. He had been on the verge of dropping out of school and moving back in with his parents, he says.

A fully trained diabetic-alert dog can cost as much as $20,000. Many families conduct fundraisers to afford them. Nonprofit training centers offer dogs free of charge, or ask for a nominal fee, but the waiting lists are long.

Andrea Calamoneri,
whose 15-year-old son Dylan has had Type 1 diabetes for nearly a decade, said she was initially skeptical. "I wasn't about to trust my son's life to something that is voodoo," she says. Seeing a dog respond to a low sugar reading convinced her. "It gives you chills when you see it happen."

Celeste, a 60-pound yellow Labrador, has been at Dylan's side for about a year. A few weeks ago, when Dylan got home from a 2½-hour wrestling practice, Ms. Calamoneri expected his sugars to drop. By bedtime, they hadn't. In the middle of the night, Celeste nudged the Danville, Calif., mother of three awake. Dylan's sugar level was 56, well below the target of 80.

"Your first reaction when you wake up is you almost want to say go back to bed, but you have to trust her and, sure enough, she's right," Ms. Calamoneri says.

She says the dog has alerted them of a pending drop in blood sugar well before the drop occurred. Celeste has missed an occasional alert, she says, which she attributes to a busy day when the dog got overly tired. Mostly, the dog naps whenever she is able, and typically the smell of a dropping sugar level will jolt her awake, Ms. Calamoneri says.

Interest in diabetic-alert dogs is rising, says
Ed Peebles,
president of the Las Vegas-based National Institute for Diabetic Alert Dogs, who says he gets up to 20 applications for a dog daily.

A family business his mother, a nurse, started a decade ago, the for-profit group has four locations, is hiring trainers and can't prepare enough dogs to keep up with demand, Mr. Peebles says. He charges $18,000 for one fully trained dog between 10 months and a 1½ years old.

Ms. Eppler's dog, Gracie, is always working. She bows to signal a low blood sugar and waves a raised paw to show a high level. When Gracie waves and then bows, it means that Abbie's sugar is high but falling. "Rarely will Gracie let Abbie get below 90," she says. "We joke that they are angels with fur."

As an older surving Type 1 diabetic (just past 32 years), the fear of low blood sugar during the night is far and away my greatest risk. The need for good blood sugars can often be outweighed by the risk of not waking up in the morning after a low blood sugar event. Over the 32 years, I have awoken to a room full of medical emergency squad folks, with an IV in my arm, with everyone asking me if I know where I am. I am now a widower, and spend much of my time alone. The risk is real, and these animals provide a MAJOR service to any family dealing with Type 1 diabetes.

Type 1 diabetes, the disease discussed in this article, is not caused by overweight or diet, as this article correctly points out. Type 1 diabetics are almost always thin. Weight loss can be a warning sign.

[Andrea Calamoneri, whose 15-year-old son Dylan has had Type 1 diabetes for nearly a decade, said she was initially skeptical. "I wasn't about to trust my son's life to something that is voodoo," she says. Seeing a dog respond to a low sugar reading convinced her. "It gives you chills when you see it happen."]

Lesia Schulha-Bobrek wrote: I am constantly perplexed by these statements from Doctors who claim that they do not know why we have an increase in diabetes in the population, especially children. Have you seen all the candy handed out in classroom throughout the day? We are rewarding our kids by raising their sugar levels throughout the day, and then the body never learns how to keep an even glucose rate because it is constantly bombarded with additional intake of sugar calories. This terrible cop-out by teachers has to stop. We need to continue to bombard our school principals with complaints and concerns about this issue to eradicate the candy train from our schools.

Back in the early 80s, I prosecuted drunk driving cases. One of the frequent excuses given for a driver's failing a breathalyzer test was that the driver was diabetic, and the condition produced ketones that were expelled in the breath. This excuse did not work as a defense against an accusation of drunk driving (excuse me, driving under the influence), but maybe the ketones are what the dogs are picking up.

Bill, I completely understand your fears about the risk of overnight lows, as I too have lived with Type I for 26 years. May I offer another suggestion? Many of my Type I friends have moved toward CGM (continuous glucose monitoring) using Dexcom and have been pleased with the results. Because Dexcom gives real-time results (every 2-5 minutes), provides trend information (up or down and speed of change), and will alarm you at a user-defined glucose level (say 80), it can avert a life-threatening low overnight. Unfortunately, the article indicated that CGMs cannot predict low sugars. That is incorrect: Dexcom CGM can indeed predict them. I will be using it soon!

Bill I am sorry.. I do not presume to be able to give advice to someone as experienced as you. But I figured you would not be offended if I shared something that helped us. This will not apply if you pump. We moved our basal to morning. That has cut our nightime hypo incidences into a very rare occurence. We did have to raise lantus in order to counteract dawn phenomenon. We also lowered lunch bolus to counteract lantus afternoon peak. Anyway God bless!

I am well aware of starvation ketones in diabetics and non diabetics but there is no evidence of ketones being present in the bloodstream of diabetics with hypoglycemia. There is a short term threat of seizure or death in diabetics, especially hypoglycemia unaware babies, toddlers and children. Ketones whether they are formed by starvation, illness, pump malfunction or dka take at least hours to form. Hypoglycemia occurs in minutes.

Most people with type 1 only go into diabetic ketoacidosis once in their lives, and that is at diagnosis. That is a statistical fact. If they do go into dka again it is usually due to illness or pump malfunction. In either case as I said ketones take time to develop. Themain purpose of the dad (diabetic alert dog) is to alert for hypoglycemia (low blood sugar) when it occurs. There is no development of ketones in the bloodstream in the occurence of low blood sugar. You don't have to go to medical school to know this. It is common knowledge for someone with type 1 diabetes. A child with type 1 knows this. If you can't understand then ask someone with type 1 and they can perhaps explain it to you. Good luck.

You are absolutely wrong. Ketones take time to develop in the bloodstream. Ketones only occur in high blood sugar and take hours or days to become dangerous depending on ones regimen. They do not develop in the incidence of low blood sugar at all. Hypoglycemia is the main and immmediate danger of type 1 diabetes. I have to wonder why you felt compelled to comment on a subject you obviously know nothing about. I live with it 24/7.

Actually, the article points out the increase is in Type 1 diabetes, which is an auto-immune response of the body, whereby the cells in the pancreas that produce insulin are destroyed. One possible explanation for the increase in the numbers of Type 1 diabetes would be the discovery of insulin and then "invention" of inject-able insulin (to treat diabetes), which was introduced in the early 1920s. With the use of insulin injections, Type 1s are no longer guaranteed a fairly rapid death upon the onset of the disease. In other words, we live longer, and can have off-spring! And diabetes is, BTW, a hereditary disease... just a theory...

Just because you weren't aware of it, doesn't mean it doesn't happen or that there's no evidence of it. You clearly aren't aware of a lot of things and yet they exist quite well without your knowledge. Thanks for the lecture, though. How many DKA patients have you been the doctor for? And no, they don't take hours to form. They don't take long to form at all. Do you even know HOW they form, you pedant? Before you go lecturing people, you need to get an education.

Great comments, Donna. You know a great deal about Type I, and I'm sorry to see that Justin Hamlin's comments have overreached his area of expertise and have devolved into personal attacks. You are correct on all counts: Ketones are an issue for HIGH blood glucose, and they can be detected in one's breath. And, according to existing scientific knowledge, Ketones are NOT a good indicator for extreme LOW sugars, which are the cause of so many unfortunate deaths for Type I diabetics. Thus the need for further research about the substance emitted.

I hope Justin will review the guidelines of this WSJ forum regarding respecting others.

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